The RANZCP Workforce Report: Action is needed, now.

OBJECTIVE: The RANZCP conducted an anonymous survey of 7200 members (trainees and psychiatrists) in December 2023, receiving 1269 responses, representing the views of roughly 1 in 6 members, and of the respondents, three quarters reported experiencing burnout in the last 3 years. We provide a commentary, citing evidence from relevant previous research, discussing the implications and proposing potential interventions. CONCLUSIONS: Members of the RANZCP reported worsening workforce shortages, with 9 in 10 respondents stating that these negatively impacted patient care, and 7 in 10 experiencing symptoms of burnout. Eighty per cent identified workforce shortages as the top contributing factor to such burnout. The aetiology of workforce shortages and burnout is likely due to operational and structural shortfalls in psychiatric services. However, public and private sector employment information was not included in the report. There are a range of strategic, evidence-based interventions to address the psychiatrist and trainee workforce challenges, comprising general healthcare service as well as specific initiatives. Based on the findings of the report, such interventions are needed, now.

Questionable evidence and argumentation regarding alleged misuse of Medicare.

What is known about this topic? We discuss a recently published paper that alleges clinicians are causal agents of non-compliant billing of Medicare. What does this paper add? The paper's arguments are partially supported by unreferenced assertions, potential logical fallacies, inaccurate reporting of referenced material and unsubstantiated rhetoric. What are the implications for practitioners? Due to the lack of substantive evidence, it cannot be concluded that clinicians are the causal agents of non-compliant billing of Medicare.

Healthcare provider data breaches - framework for crisis communication and support of patients and healthcare workers in mental healthcare.

Increasing numbers of healthcare data breaches highlight the need for structured organisational responses to protect patients, trainees and psychiatrists against identity theft and blackmail. Evidence-based guidance that is informed by the COVID-19 pandemic response includes: timely and reliable information tailored to users' safety, encouragement to take protective action, and access to practical and psychological support. For healthcare organisations which have suffered a data breach, insurance essentially improves access to funded cyber security responses, risk communication and public relations. Patients, trainees and psychiatrists need specific advice on protective measures. Healthcare data security legislative reform is urgently needed.

Comparison of the out-of-pocket costs of Medicare-funded telepsychiatry and face-to-face consultations: A descriptive study.

OBJECTIVE: Telepsychiatry items in the Australian Medicare Benefits Schedule (MBS) were expanded following the COVID-19 pandemic. However, their out-of-pocket costs have not been examined. We describe and compare patient out-of-pocket payments for face-to-face and telepsychiatry (videoconferencing and telephone) MBS items for outpatient psychiatric services to understand the differential out-of-pocket cost burden for patients across these modalities. METHODS: out-of-pocket cost information was obtained from the Medical Costs Finder website, which extracted data from Services Australia's Medicare claims data in 2021-2022. Cost information for corresponding face-to-face, video, and telephone MBS items for outpatient psychiatric services was compared, including (1) Median specialist fees; (2) Median out-of-pocket payments; (3) Medicare reimbursement amounts; and (4) Proportions of patients subject to out-of-pocket fees. RESULTS: Medicare reimbursements are identical for all comparable face-to-face and telepsychiatry items. Specialist fees for comparable items varied across face-to-face to telehealth options, with resulting differences in out-of-pocket costs. For video items, higher proportions of patients were not bulk-billed, with greater out-of-pocket costs than face-to-face items. However, the opposite was true for telephone items compared with face-to-face items. CONCLUSIONS: Initial cost analyses of MBS telepsychiatry items indicate that telephone consultations incur the lowest out-of-pocket costs, followed by face-to-face and video consultations.

The changing psychiatry workforce in Australia: Still lacking in rural and remote regions.

INTRODUCTION: There is a long standing and worsening shortage of psychiatrists in Australia particularly in rural areas. The majority of psychiatrists work in major cities. OBJECTIVE: To identify recent trends in the Australian rural psychiatrist workforce compared with the metropolitan workforce. DESIGN: We descriptively analysed population-level data from the National Health Workforce Data Set (NHWDS), the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS). A descriptive analysis of the numbers (count) and gender of psychiatrists from 1995 to 2022 working in Australia was conducted. For the period 2013 to 2022, we analysed for rurality, gender, years' experience, hours worked, Medicare-subsidised services provided and proportions of Specialist International Medical Graduates (SIMG) by sex, with a focus on the rural workforce. For international comparison, psychiatrist numbers were obtained for other OECD countries. The number of psychiatrists working in Australia, as per NHWDS and AIHW, was quantified. We analysed trends in demographics, hours worked and rurality of psychiatrists working in Australia in a serial cross-sectional design. FINDINGS: Most psychiatrists are maldistributed to major cities, while outer regional and remote areas have few resident psychiatrists. Outer regional New South Wales (NSW) and South Australia (SA) have the lowest numbers of psychiatrists per capita. The full-time equivalent (FTE) of psychiatrists per 100 000 has increased from 12.6 in 2000 to 15.2 in 2022. However, the average hours worked by psychiatrists has declined. In total, available psychiatrist hours worked per 100 000 population has increased by 6.1% since the beginning of the millennium. DISCUSSION: Rural areas in NSW and SA have the greatest shortage of psychiatrists. Specialist International Medical Graduates and females (43% of the overall workforce) are the predominant workforce in rural areas. Although Medicare-subsidised services per 1000 people have increased in rural areas, they remain lower than for those living in major cities. CONCLUSION: There remains an acute shortage of psychiatrists in many regional and remote areas of Australia, with an increasing proportion of SIMGs and females working in these areas, in the context of future increased demand.

Seasonal Surge for Mental Health Demand in Emergency Departments.

Objective: To analyze emergency department (ED) mental health presentations over a 7-year period to estimate the timing and magnitude of the seasonal effect across Australia.Methods: We analyzed data collected by the Australian Institute of Health and Welfare (AIHW) from 2014-2015 to 2020-2021, which included all public hospital ED presentations in Australia that received a mental health diagnosis per the Australian Modification of ICD-10. The data were divided into 4 sequential quarters (Q1 = July-September, Q2 = October-December, Q3 = January-March, Q4 = April-June) and analyzed by sex and age (youth: 18-24 years, adult: 25-64 years, and older adult: > 65 years). Regression analysis was used to assess seasonal variation.Results: On average, mental health ED presentations were 9% higher in October-December than April-June, which had the lowest rates of mental health ED presentations for males and females. The peak continued into January-March, most prominently for females. Seasonality was evident in the 18-24 and 25-64 age groups. There were increased ED psychiatry presentations in October-December of 14.4% (males) and 9% (females) in the group aged 18-24, as well as increases of 10.3% (males) and 10.1% (females) in those aged 25-64. In January-March, there was an increase in presentations for females of 7% (aged 18-24) and 10.3% (aged 25-64). For adults aged > 65, there were increased presentations in July-September compared to April-June of 4.9% (males) and 3.9% (females).Conclusions: We found strong, statistically significant peaks in mental health ED presentations in spring and summer. Mental health services need to plan for significantly higher ED mental health demand during these seasons. Further research is required to estimate the size of the mental health seasonal effect in acute hospital settings.Prim Care Companion CNS Disord 2024;26(1):23m03629. Author affiliations are listed at the end of this article.

Psychiatric electronic health records in the era of data breaches - What are the ramifications for patients, psychiatrists and healthcare systems?

OBJECTIVE: To update psychiatrists and trainees on the realised risks of electronic health record data breaches. METHODS: This is a selective narrative review and commentary regarding electronic health record data breaches. RESULTS: Recent events such as the Medibank and Australian Clinical Labs data breaches demonstrate the realised risks for electronic health records. If stolen identity data is publicly released, patients and doctors may be subject to blackmail, fraud, identity theft and targeted scams. Medical diagnoses of psychiatric illness and substance use disorder may be released in blackmail attempts. CONCLUSIONS: Psychiatrists, trainees and their patients need to understand the inevitability of electronic health record data breaches. This understanding should inform a minimised collection of personal information in the health record to avoid exposure of confidential information and identity theft. Governmental regulation of electronic health record privacy and security is needed.

Medicare Benefits Schedule (MBS) Review Advisory Committee post-implementation review of MBS telehealth items: abolition of initial telehealth consultations for non-general practitioner specialists.

In 2022, the Australian Federal Minister for Health and Aged Care commissioned the Medicare Benefits Schedule (MBS) Review Advisory Committee (MRAC) to conduct a post-implementation review of MBS telehealth services, including settings of video and telephone consultations. The MRAC has made a series of administrative recommendations for telehealth practice that appear at cross-purposes to the evidence-base on medical consultations and that would limit patient access to medical specialist assessment in Australia. These recommendations particularly underestimate the role of telehealth in rural and remote Australia and did not take into account high patient satisfaction with telehealth assessment and treatment during the ongoing coronavirus disease 2019 (COVID-19) pandemic. They also appear to contradict the Medical Board of Australia's guidance on telehealth. On this basis, the recommendations for telehealth principles and abolition of reimbursement for telehealth for all initial non-general practitioner medical specialist consultations should be withdrawn.

Practical psychiatry: On therapeutic equipoise - Principles of a balanced approach to psychiatric treatments.

OBJECTIVE: There are many burgeoning treatments, and a large range of therapeutic options for 21st century psychiatry. This paper briefly comments upon considerations for balancing treatment to suit the patient, their illness, and their milieu. CONCLUSIONS: Therapeutic equipoise, for psychiatric care, is an aspiration rather than a position easily achieved. In day-to-day clinical practice, there will be unexpected demands and barriers that cannot always be accommodated or surmounted. Psychiatrists can work collaboratively with patients, carers, and colleagues in conceptualising and care-planning to avoid extremes of therapeutic hubris and despair, and to adapt evidence-based care more effectively so that it is suited to the patient and their circumstances.

Practical psychiatry: Taking gaming seriously - a primer for psychiatrists on gamers and gaming culture.

OBJECTIVE: Up to three billion, of the eight billion people in the world, play videogames. Gaming is a significant global sociocultural influence. This primer will aid psychiatrists in understanding sociocultural milieux of gamers, who include patients and their communities. METHOD: A rapid narrative review. RESULTS: Benefits include expression of personality, identity and culture through social aspects of gaming. Improved physical health, neurocognition, self-efficacy and quality of life are associated with gaming in those with certain mental health disorders including schizophrenia. Harms may include in-game discrimination, disordered gaming, as well as encouragement of online gambling. There is no longitudinal association between violent games and youth aggression. CONCLUSIONS: Psychiatrists should enquire about gaming as part of the sociocultural milieux of patients' lives, and the perceived mental health benefits and harms of gaming.

Unpeeling the onion: Digital triage and monitoring of general practice, private psychiatry, and psychology.

OBJECTIVE: The Australian federal government is considering a 'digital front door' to mental healthcare. The Brain and Mind Centre at the University of Sydney has published a discussion paper advocating that the government should adopt a comprehensive model of digital triage and monitoring (DTM) based on a government-funded initiative Project Synergy ($30 million). We critically examine the final report on Project Synergy, which is now available under a Freedom of Information request. CONCLUSION: The DTM model is disruptive. Non-government organisations would replace general practitioners as care coordinators. Patients, private psychiatrists, and psychologists would be subjected to additional layers of administration, assessment, and digital compliance, which may decrease efficiency, and lengthen the duration of untreated illness. Only one patient was deemed eligible for DTM, however, during the 8-month regional trial of Project Synergy (recruitment rate = 1/500,000 across the region). Instead of an unproven DTM model, the proposed 'digital front door' to Australian mental healthcare should emphasise technology-enabled shared care (general practitioners and mental health professionals) for the treatment of moderate-to-severe illness.

Mitigating the consequences of electronic health record data breaches for patients and healthcare workers.

Electronic health records (EHRs) have been widely adopted in Australian public sector healthcare and will remain an ongoing, essential data system. However, recent substantial data breaches from hacked business data systems in Australian enterprises, as well as international healthcare providers, mean that EHR data breaches are increasingly likely in Australia. Risks include medical identity theft and extortion attempts based on threats to release sensitive patient information. Hacking is now a foreseeable additional risk of medical treatment. Risk mitigation for the consequences of data breaches needs to be considered, as well as support for patients (and families) and healthcare workers. This includes identity theft protection services, cybersecurity insurance, and psychological support.

Systematic Review of Psychiatric Observation Units and Their Impact on Emergency Department Boarding.

Objective: To investigate the effectiveness of acute short-stay hospital admissions in psychiatric observation units for improving the flow of patients with mental health presentations through the emergency department (ED).Data Sources: CINAHL, MEDLINE, OVID, PsycINFO, PubMed, Web of Science, and Google Scholar were systematically searched for English-language studies from 1990 onward. Descriptors used to describe psychiatric observation units were identified, and in databases with MESH term availability, the terms "mental disorder" and "emergency services, psychiatric" were also utilized to further enhance the search.Study Selection: A total of 6,571 studies were screened. The PICOS framework was used to determine the inclusion and exclusion criteria, and the process of study selection followed PRISMA guidelines. Articles were included if the unit studied had a length of stay (LOS) < 72 hours and if patients suffered from a mental health condition and were treated as hospital inpatients.Data Extraction: Reviewers performed data extraction and quality assessment of the included studies following the review protocol.Results: A total of 14 psychiatric observation unit studies were included in the review: 5 in North America and 9 in Australia. Most of these units were in large urban general hospitals. There appears to be some improvement in ED LOS for patients with mainly crisis mental health presentations. Seven of the 14 studies specifically discussed ED LOS, and 6 of these studies showed mild to moderate improvement in ED LOS, ranging from 17 minutes to > 11 hours.Conclusions: Psychiatric observation units were mainly located in North American and Australian settings. These units may reduce ED LOS based on limited, poor-quality evidence. Further research is required to determine whether psychiatric observation units have ongoing effects on ED LOS and alleviate access block.Prim Care Companion CNS Disord 2023;25(6):22r03468. Author affiliations are listed at the end of this article.

The unfulfilled promises of electronic health records.

We provide a brief update on the current evidence on electronic health records' benefits, risks, and potential harms through a rapid narrative review. Many of the promised benefits of electronic health records have not yet been realised. Electronic health records are often not user-friendly. To enhance their potential, electronic health record platforms should be continuously evaluated and enhanced by carefully considering feedback from all stakeholders.

What have been the clinical outcomes of the Project Synergy/InnoWell digital health platform?

Project Synergy is a digital mental health tool for assessment, referral and follow-up of people with mental health problems. The Australian federal government Department of Health entered an AUD33 million formal funding arrangement with InnoWell, a proprietary company vehicle (primarily the consultancy firm PwC and University of Sydney) to continue development of Project Synergy. This followed an initial federal National Health and Medical Research Council grant of AUD5.5 million over the previous 3 years. However, based on the assessment of peer-reviewed research data, the Project Synergy/InnoWell platform does not seem to have demonstrated clinical outcomes of healthcare value to date.

Deterioration of mild anxiety and depression with Better Access treatment: implications for scaling up psychotherapy worldwide.

The Australian Medicare Better Access initiative in mental health reached one in every 10 Australians in 2021 (more than 2.6 million people) with interventions targeted at mild-to-moderate anxiety and depression, provided by general practitioners, allied health professionals, and/or psychiatrists, at a cost of AUD1.2 billion. However, the overall mental health of the Australian population has not improved since the introduction of Better Access. The benefits of population-scale mental health interventions (medications and psychotherapies) might have been overestimated for milder conditions, and the iatrogenic potential underestimated. A recent evaluation of Better Access found that mild anxiety and depressive symptoms were threefold more likely to worsen (32%) rather than improve (10%). Better Access might be targeted more cost-effectively towards severe and complex conditions, for which treatment appears to have superior risk-benefit ratios. These findings have implications for similar initiatives worldwide, such as those proposed by the World Health Organization.

A systematic review of the role of clozapine for severe borderline personality disorder.

RATIONALE: Clozapine is a unique medication with a potential role in the treatment of severe borderline personality disorder (BPD). OBJECTIVES: The review examines the effectiveness of clozapine as a medication for management for severe BPD with high risk of suicide, violence or imprisonment, and aims to help guide clinical practice in managing severe BPD. METHODS: A database search of the terms "Clozapine" AND "BPD"; "Antipsychotics" AND "BPD"; "Clozapine" AND "Borderline Personality Disorder"; and "Antipsychotics" AND "Borderline Personality Disorder" were performed in CINAHL, Cochrane Library, Embase, Medline, PsychINFO, PubMed, and Web of Science. Full-text articles of clinical clozapine use for BPD were included for review. RESULTS: A total of 24 articles consisting of 1 randomised control trial, 10 non-controlled trials, and 13 case reports were identified. Most of the studies reported benefits from clozapine when used for severe BPD. Many of the studies focused on clozapine use in BPD patients at high risk of suicide. Results from these non-controlled and case reports support the use of clozapine in patients with severe BPD at high risk of suicide. CONCLUSION: There may be a role for clozapine in treating severe treatment refractory BPD, especially for those patients at high risk of suicide and frequent hospitalisations.